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Obstetric Fistula: the Role of Physiotherapy: a Report from the Physiotherapy Committee of the International Continence Society

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Obstetric Fistula: the Role of Physiotherapy: a Report from the Physiotherapy Committee of the International Continence Society Received: 11 July 2018 | Accepted: 11 September 2018 DOI: 10.1002/nau.23851 SOUNDING BOARD Obstetric fistula: The role of physiotherapy: A report from the Physiotherapy Committee of the International Continence Society Gill Brook MCSP (DSA)CSP, MSc | The ICS Physiotherapy Committee International Organization of Physical Therapists in Women's Health, Burras Aims: To discuss the role of physiotherapy in the management of women who have Lynd, Otley, West Yorkshire, United suffered an obstetric fistula, referring to research findings when appropriate and Kingdom available, and the experiences of clinical specialists in the field. Correspondence Methods: The experiences of physiotherapists who have worked in countries where Gill Brook, Burras Lynd, Burras Lane, obstetric fistula is prevalent, and the limited literature available, were considered in Otley, West Yorkshire, LS21 3ET, United producing this consensus document on behalf of the ICS Physiotherapy Committee. Kingdom. Email: [email protected] Results: The role of physiotherapy both pre- and post-fistula repair was identified, and is multi-faceted. Women may have general rehabilitation needs based on the obstructed labor itself and subsequent care. All affected women may benefit from pelvic floor muscle assessment, education and exercises to optimize the outcome of their surgery; further pelvic floor physiotherapy may be indicated for those who experience persistent genitourinary dysfunction following closure of the fistula. Conclusions: Further robust research is required to confirm the effectiveness of physiotherapy in the management of women who have suffered an obstetric fistula and the optimum development of such services. Based on the available literature and the experience of physiotherapists in the field, there was consensus within the ICS Physiotherapy Committee that patient outcomes can be improved if physiotherapy is provided as part of the multidisciplinary team. Physiotherapy should not be overlooked when fistula services are being developed. KEYWORDS physiotherapy, rectovaginal fistula, vesicovaginal fistula 1 | INTRODUCTION fistula as a result of obstructed labor each year while several million women live with the effects of the injury.1 Although accurate figures are not available, it has been The role of physiotherapy in the management of women estimated that 50 000-100 000 women develop an obstetric who have suffered an obstetric fistula (OF) has been recognized by previous authors.2–4 A physiotherapist brings Diane Newman led the peer-review process as the Associate Editor specific knowledge and skills, contributing to quality of care responsible for the paper. and optimum outcomes. This paper will discuss the role of physiotherapy, referring to research findings when appropri- In line with the journal's guidance on Author Contributions, members of the ICS Physiotherapy Committee who commented on the draft document ate and available, and the experiences of clinical specialists in are listed in the Acknowledgments section. the field (see Acknowledgments). It will be neither an Neurourology and Urodynamics. 2019;38:407–416. wileyonlinelibrary.com/journal/nau © 2018 Wiley Periodicals, Inc. | 407 408 | BROOK exhaustive list of services, nor prescriptive, but should offer compensatory adaptation. There were no recommendations an overview of current and potential physiotherapy provision. on physiotherapy to address these findings, but a treatment The role will be discussed in terms of general rehabilitation, program can be developed to meet the specific needs of the and specific pelvic floor physiotherapy. woman with focus on recovery of her ability to carry out the activities of daily living necessary for post-operative 2 | ROUTINE PHYSIOTHERAPY reintegration into her community. ASSESSMENT 3.2 | General weakness Physiotherapy assessment (Appendix 1) may be undertaken As a result of prolonged immobility, with resultant muscle pre- or post-repair and should be patient specific.2 atrophy ± poor nutrition and comorbidities, women can experience general weakness and deconditioning. The goals 3 | GENERAL PHYSICAL of physiotherapy will be to improve muscle strength and REHABILITATION function, exercise tolerance, mobility, and ability to under- take activities of daily living. Although some women will present in relatively good general For women with such physical rehabilitation needs it is health, in countries where OF is prevalent, others may be difficult to accurately predict how long recovery will take or experiencing general weakness, walking difficulties, foot how complete it will be, particularly in the case of foot drop or drop, or joint contractures. These may be associated with the contracture. It is not an area that has been researched to date. obstructed labor itself or management during the postnatal Whereas a woman with simple foot drop may be fit for period when it is not uncommon for women to lie down for surgery and subsequent discharge very quickly (albeit with an prolonged periods in the hope that their incontinence will altered gait if the loss of ankle dorsiflexion does not resolve), stop. Timely physiotherapy is indicated to address these a woman with marked joint contractures may require many dysfunctions. months of treatment both pre- and post-operatively. Although pre-operative rehabilitation may help ensure 3.1 | Foot drop and contractures that a woman is fit to go home soon after surgery, there are undoubtedly women who will benefit from physiotherapy Foot drop has been reported in up to 30% of women following post-operatively to enhance their physical recovery. OF in Ethiopia5 with both a lower6 and higher7 incidence noted elsewhere. If left unattended, and compounded by a 3.3 | Group exercises lack of mobilization, it can result in not only ankle but other lower limb joint contractures. It is probably due to While some treatments will require one-to-one attention from compression of the lumbosacral nerve trunk within the pelvis the physiotherapist, much can be undertaken satisfactorily in during the obstructed labor, or peroneal nerve injury related to a group of women with similar impairments and rehabilitation prolonged squatting.8 Foot drop may vary from “simple” (no needs. This is not only an efficient and cost-effective use of a tightness of the Achilles tendon and full passive dorsiflexion) healthcare professional's time, but also an opportunity for through to “severe” where passive dorsiflexion is severely women to meet other patients—possibly at different stages of limited, and the woman may walk on her toes. The goals of recovery—and share common experiences and concerns. physiotherapy will be to prevent or reduce joint contracture, Exercise interventions will depend very much on the facilitate muscle activity, enable independent mobility, and rehabilitation needs and physical capabilities of the women independence in activities of daily living. In complex cases, concerned, facilities, and the equipment available, plus the and subject to availability, serial casting or even surgery may knowledge and skills of the clinicians involved. An exercise be needed if more conservative measures fail. program should be developed with consideration of the Functional electrical stimulation (FES) has been used in available evidence and best practice at the time. It may be the management of foot drop for many years and has been appropriate to include warm-up and stretch, posture correc- shown to be both effective and preferred by some patients tion, and a range of exercises that could include medium level (following stroke) when compared to use of an orthosis.9 aerobic, balance, muscle strengthening, mobility, and However, it may not be an option due to a lack of equipment functional activities. or suitably skilled staff. 6 Tennfjord et al found that walking difficulties were 3.4 | Activities of daily living common in women with OF, who demonstrated decreased ankle and knee range of movement, but increased Physiotherapy should always consider the needs of the hip movement and muscle strength, possibly due to individual, including their social circumstances. In BROOK | 409 countries where OF is prevalent, many women undertake A voluntary PFM contraction just before and during a heavy work on a daily basis at home and in employment, so cough, referred to as “The Knack,”15 has been shown to rehabilitation should integrate appropriate functional activ- reduce leakage significantly in women with stress urinary ities such as lifting and carrying. Women who have suffered incontinence. It might also be prudent to teach “The Knack”15 an OF will almost inevitably have sub-optimal function of to women following OF; with coughing, other increases in their pelvic floor and associated muscles in addition to any intra-abdominal pressure, and with urinary urgency, to of the impairments previously described. Therefore the minimize the risk of leakage and reduce pressure on the importance of correct body mechanics should be empha- pelvic floor. sized to optimize recovery, facilitate a return to normal In addition to PFME, Castille et al10 advised women on activities, and reduce the risk of further injury or measures to reduce pressure on their pelvic floor and repair dysfunction. site, with posters on display within the healthcare facility to reinforce this message. The poster included diagrams of tasks which should be avoided and a good lifting technique among 4 | PELVIC FLOOR other pictorial advice. This is a potentially useful measure in PHYSIOTHERAPY
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